Provider Demographics
NPI:1083105878
Name:ROO, KUNMIN
Entity Type:Individual
Prefix:DR
First Name:KUNMIN
Middle Name:
Last Name:ROO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1316
Mailing Address - Country:US
Mailing Address - Phone:309-681-8888
Mailing Address - Fax:888-293-9991
Practice Address - Street 1:5025 UTICA RIDGE RD STE 103
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3035
Practice Address - Country:US
Practice Address - Phone:563-345-8888
Practice Address - Fax:888-250-2562
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031889122300000X
IADDS-09595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist